Basic Information
Provider Information | |||||||||
NPI: | 1437313863 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIMA MEDICAL FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4 HAMILTON LANDING | ||||||||
Address2: | SUITE 100 | ||||||||
City: | NOVATO | ||||||||
State: | CA | ||||||||
PostalCode: | 94949 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4158841840 | ||||||||
FaxNumber: | 4158837127 | ||||||||
Practice Location | |||||||||
Address1: | 651 1ST STREET WEST | ||||||||
Address2: | SUITE H | ||||||||
City: | SONOMA | ||||||||
State: | CA | ||||||||
PostalCode: | 95476 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7079383870 | ||||||||
FaxNumber: | 7079383895 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2008 | ||||||||
LastUpdateDate: | 08/16/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CRISTE | ||||||||
AuthorizedOfficialFirstName: | JOEL | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4158841840 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PRIMA MEDICAL FOUNDATION | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   | 208000000X | G55637 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 208600000X | A65187 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   | 208000000X | A66490 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 208D00000X | A106783 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   | 207R00000X | A92199 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.